Mutuelle

Shortly after I arrived, Elie and Consolate brought me up-to-speed on their efforts on Mutuelle (community insurance). It’s one of my big projects here and it consists of three goals:

1. Boost Mutuelle enrollment in the Shingiro catchment area for 2010
2. Develop a report for the District Mayor on common barriers to enrollment and recommendations to overcome those barriers.
3. Liaise with the Shingiro Mutuelle office as part of the broader effort to make Shingiro a better health center

Mutuelle enrollment costs RWF 1,000 per household member for each year. The Mutuelle-subscription year corresponds to the calendar year. To prevent people from only purchasing Mutuelle when they become sick, aka to prevent adverse selection, Mutuelle must be purchased before the year begins. If families wait until the subscription year to purchase Mutuelle, they face a 30-day waiting period before their Mutuelle enrollment becomes active and can only purchase for the current year until June. Mutuelle enrollment for the next year begins in August. Thus, from now until the end of December is the important period for enrolling community members. An additional measure against adverse selection, heads of household must purchase Mutuelle for every member of their households, not just those that are mostly likely to become sick.

Mutuelle enrollment is the key to creating access to the formal health system in Rwanda. Indeed, looking at the data from 2008 in the Musanze district, there is a strong correlation between Mutuelle enrollment and health center use at the 11 health centers:

*I should note, in loyalty, fairness, and kudos to CCHIPS, that “Mutuelle Enrollment vs. Target” and “New Cases Seen vs. Target” in Shingiro are both up considerably in 2009 - no doubt helped by CCHIPS involvement.

While correlation does not prove causality there are a few points of reality that make the distinction moot:

• Mutuelle is a great deal for its members. The true cost of health care is far higher than the RWF 1,000 enrollment fee, which is ‘only’ about $2. Mutuelle is subsidized by various NGOs and the government. Thus, beyond the normal insurance functions of consumption smoothing, risk pooling and so on, Mutuelle gives preferential access to the health center vs out of pocket payers.
• We do see enrollment creep up between January and June, as people recognize that they need Mutuelle after they get sick. However, this just reinforces the argument for educating people about the cost-savings of using Mutuelle before they get sick. Mutuelle creates access to health centers at an affordable price.
• The subsidization means that adverse selection is less of a problem, in the short run at least. Very few families have a risk profile for illness that makes not purchasing Mutuelle a good bet.

Therefore, I suspect that the Mutuelle enrollment rate indicates the proportion of the population that a. believes in the formal healthcare system vs traditional healers or doing nothing at all and b. is able to pay for coverage.

Focusing on Mutuelle enrollment allows the health center to ‘bag’ wins and concentrate its ‘sales’ effort within a relatively small window of time. We don’t have to expend significant resources all year round trying to one-off convince people on the benefits of using the health center. We know how many people will use the health center based on our enrollment figure, and we know the time period that we need to focus on to sell health center use for the whole next year.

A question raised by the subsidization of Mutuelle is: ‘if you are already heavily subsidizing the system, why not just give free healthcare to everyone? Why make people pay anything at all, if that will get them to use health services more often?’

There are a few reasons:

• The poorest (“indigents” in local parlance) receive financial aid to cover the Mutuelle enrollment fee (though we are looking at the current system of identifying these people – it does not work very well).
• Forcing people to pay for at least part of the cost of care helps prevent adverse incentives from forming (such as creating a sense of entitlement, etc). It might also create good habits and general acceptance of health insurance as ‘just something you do’.
• NGO pockets are deep, but not limitless. In fact, we are currently doing analyses of what would happen to the Shingiro budget if various sources of income were delayed or ceased (my working hypothesis: if Mutuelle cut back on its reimbursements, the health centers would quickly become insolvent).
• Most important is the recognition that the current system is developing alongside the Rwandan economy. The goal is for most parts of the healthcare system to not fundamentally change when the system becomes self-sustaining. It is important to sensitize (a favorite word of Rwandan technocrats) the population to the benefits of using the health centers, even if they cannot afford them currently. Indeed, using the health centers now might help people be able to afford them in the future. The hope is for the development of a virtuous cycle with better health standards driving income growth driving a greater ability and willingness to pay for health services.

Despite these qualifications, it is clear that Mutuelle is not an ideal system for paying for care. However, it’s hard to imagine an ideal system, given the willingness to pay for most people is lower than the cost of providing healthcare. But we’re not here to create an ideal system. We are working at a local level; we are not trying to redesign the Rwandan healthcare system or how the government should ask its citizens to pay for that system. We are trying to help the health center staff maximize the quality and usage of the health center in a way that is implementable, replicable, and can be easily monitored. Mutuelle is clearly important to this effort.